Knee effusion and quad inhibitionThreshold


Threshold for reflex inhibition of
vastus medialis 20-30 ml, rectus
femoris and vastus lateralis 50-60
ml. Spencer JD et al Arch Phys
Med Rehabil 1984
Knee effusion [60 cc] resulted in
profound inhibition of reflexively
evoked quad contraction. Kennedy
JC AJSM 1982.
Knee effusion and quad
inhibition- Mechanism?


Most initial strength gains are
neural- “Studies of early voluntary
strength gains show large increases
in muscle performance prior to
development of hypertrophy”.
Chmielewski TL et al J Ortho Res
2004
Neural factors [vs. hypertrophy]
accounted for larger proportion of
strength increase in 1st 3-5 wks.
Moritani T Am J Phys Med 1979
Knee Effusion Assessment




Stroke Test
(0 to 3+)
Stroke up
from Med.
Jt. Line,
down from
suprapat.
Pouch to lat
jt. line
Sturgill LP
et al. JOSPT
2009
Effusion Grading Scale of the
Knee Joint






Based on the Stroke Test
Zero No wave produced on downstroke
Trace Small wave on medial side with
downstroke
1+ Larger bulge on medial side with
downstroke
2+ Effusion spontaneously returns to medial
side after upstroke (no downstroke
necessary)
3+ So much fluid that it is not possible to
move the effusion out of the medial aspect of
the knee
Limiting quad inhibition and
restoring voluntary control
• Compressive wrap/sleeve
• Cryotherapy with elevation
• Biofeedback
• E-stim
Compressive wrap/ sleeve• Less slippage with
neoprene sleeve
• Helps maintain
sterile wound cover
• May also have +
impact on
proprioception
***Must maintain
sterile wound
precautions with
each.
Wilk KE (instructional
course) and Wilk KE at al
Orthop Clin N Amer 2003
Cryotherapy Evidence
• Assists with pain control and effusion
control.
 Hopkins JT J Athl Train 2006Cryotherapy ↓ quad inhibition, ↑ knee
power torque versus controls
 Hubbard TJ J Athl Train 2004Cryotherapy efffective in ↓ pain
 Raynor MC et al J Knee Surg
2005- Cryotherapy ↓ pain but no
effect on ROM
Cryotherapy Devices- Assists
with pain and effusion control
Limiting quad inhibition and
restoring voluntary control
• BiofeedbackLimited research
but evidence shows
clinically significant
benefit after 6 wk
protocol to recover
peak torque.
Draper V Phys
Ther 1991
• ↑ Sensory feedback
to patient to allow
increased selective
muscle activation
Neuromuscular Electrical
Stimulation
• Russian and Hi Volt
Galvanic stimulation
(HVGS)- HVGS and
alternative wave forms
with e-stim may assist
with swelling and/or pain
control via gate
theory…..but primarily
used in early rehab for
quad activation…………..
NMES Use After ACLR- Evidence

Snyder-Mackler L et al JBJS 1991,
Snyder-Mackler L et al JBJS 1995
• High intensity e-stim produced clinically
significant improvement with quad strength
and gait (flx/ext excursion in stance) versus
volitional exercise and low intensity e-stim
groups
• Problems with study- Positioning resulted in ↑
ant. Knee pain, necessitated revised protocol…..
NMES Use After ACLR- A Kinder,
Gentler Approach- Fitzgerald GK et al
JOSPT 2003
• Revised positioning to ↓ ant. knee pain but same
parameters…..produced smaller yet still clinically
significant treatment effect versus control group
at 12 and 16 weeks.



Performed in full passive knee ext. to ↓ patellar sx
c/o
Parameters used= Russian e-stim @ 10”on:50”
off x 10 mins. @ 75 bursts/sec., 2 secs ramp
Evidence of sup. patellar glide…full tetanic
contraction
NMES Use Cont’d



Hasegawa S et al J Electromyo Kinesiol
2011
Estim group showed less decline in knee
extensor strength ( 4 wks p.o.) and
greater knee ext. strength recovery (3
mos. P.o.) and greater vastus lateralis
thickness versus control grp
Kim KM et al JOSPT 2010- NMES+exer.
More effective at restoring quad strength
than exer. alone
Portable NMES versus Plug-In
Portable units
versus plug-in –
Empi 300 PV
comparable
torque
production to
plug-in unit.
Lyons CL et al Phys
Ther 2005
NMES Assisted Exercise
NMES Use to Increase Extension
ROM

Solomonow et al AJSM 1987demonstrated reflexive hamstring
activation in case of ACL-damage.
Often seen clinically with hamstring
spasm and flexed knee in acute ACL
tear pts.
• E-stim at quads may overcome this via
reciprocal inhibition and enable
restoration of quad fxn and ext ROM.
Knee extension ROM biomechanics
Inability to extend the
knee fully results in:
• abnormal jt.
arthrokinematics
• ↑ in p-f and tib.-fem.
contact pressure
• inability to contract
quads
• muscular fatigue
Wilk KE et al. Ortho Clin
N. Amer 2003
Obtaining full knee extension ROM

Active

Static

Restoration of patellar mobility

Scar mobilization

Low load long duration stretching for
HEP
Obtaining full knee ext. ROM

Active- use of
Russian NMES to
facilitate, prefer
active vs. passive
to improve
voluntary
neuromuscular
control
Obtaining full knee extension ROM
Static stretchesSave static
stretches until
mid/end of rehab
session when
tissue
viscoelasticity is
better
Restoration of Patellar Mobility- Avoid
Infrapatellar Contracture Syndrome
Paulos LE, Rosenberg
TD, Drawbert J,
Manning J, Abbott P.
Am J Sports Med. 1987
Jul-Aug;15(4):331-41
Who’s highest Risk
Category?????
PATELLAR TENDON
GRAFT
Restoration of Patellar Mobility
4 Way Patellar Mobs beginning @
initial eval with care to avoid incision
Obtaining full knee extension
ROM- Scar Mobilization
Scar mobilization- prevent adhesions
to underlying tissue
Total End Range Time (TERT)
Principle

Phys Ther. 1994 Dec;74(12):1101-7.
The use of splints in the treatment of joint
stiffness: biologic rationale and an algorithm
for making clinical decisions.
McClure PW, Blackburn LG, Dusold C

TERT (total end range time)- to
cause permanent elastic deformation
tissue changes- must be in end
range position total of 60 mins./day
Low Load Long Duration
(LLLD) stretching for HEP
prn with ≤ 10 lbs. overpressure- long
sitting (heel propped with towel),
supine, or prone
Risks of Inadequate/Incomplete
ROM restoration


Knee OA risk was 2x
greater in ACLR pts.
with abnormal ROM
(ext. ROM not within
2° opp. Knee and flx
ROM not within 5°
opp. Knee) at min. 5
yr. f/u
Shelbourne KD et al
AJSM 2012 Jan.
Risks of Inadequate/Incomplete
ROM restoration


Shelbourne KD et al
AJSM 2009
Loss of 3-5° ext.
adversely affected
SUBJECTIVE and
OBJECTIVE post-op
results, especially
when coupled with
meniscectomy or
articular cartilage
damage
Hyperextension- How much should we
strive to regain in hyperflexible athletes?
Restore only 5°
hyperextension,
if athlete
demonstrates
more ext. ROM
on contralateral
knee, allow to
gradually regain
Wilk KE et al J Athl Train
1999-
ROM Exercises- precautions?
Safe to begin as soon as ROM and
pain allows post-op
• Wright RW et al J Knee Surg
2008 (review)- Early motion is
safe and may help avoid problems
with later arthrofibrosis
• Cascio BM et al Clin Sports Med
2004 (review)- Early joint motion
after ACLR can ↓ pain, lessen adverse
changes in articular cartilage, and
prevent capsular contraction.
ROM Exercises- precautions?
Fleming B et al AJSM
1998- Stationary
bicycling at increased
resistance levels did not
significantly ↑ ACL strain
Meyers et al Clin J
Sport Med 2002Stairmaster is viable and
safe alternative to cycle
use for post-op ACLR
rehab
ROM Exercises-When to begin?
Biking, Elliptical Trainer, and
Stairmaster are acceptable when:
• ROM sufficient (generally ≥ 90°
knee flexion)
• Pain and effusion are controlled
• Weight bearing and gait are
normalized and symmetrical for
Elliptical and Stairmaster
Post-op WB- When to begin WB
and how much????
Post-op WB- Evidence
• Beynnon B et al Clin Ortho Related
Res. 2002, Beynnon BD et al AJSM
Dec. 2011- “Findings indicate that WB
IMMEDIATELY after ACLR does NOT seem
to produce excessive loads across a healing
graft that permanently deform the graft or
its fixation AND is beneficial because it
lowers incidence of patellofemoral pain”
• Tyler T et al Clin Orthop Relat Res.
1998- Immediate WB after ACLR did not
compromise jt. stability and resulted in
better outcome with ↓ incidence of ant. knee
pain.
Post-op WB Progression Guidelines
• Ideally both crutches 7-10 days
• Progress to 1 crutch then FWB without crutch by
10-14 days
• Goal is to assume full body weight on involved LE
during 2nd wk post-op.
******* Modify given concomitant pathology/procedures
(i.e. articular cartilage, meniscal repair, etc.)
• Wilk KE et al. Ortho Clin N. Amer 2003
Proprioception and Gait

Adverse effects
of ACL rupture
and invasive
reconstruction on
proprioception
and throughout
gait cycle, but
effects vary in
each individual!
Quad wknss and Effect on Gait



Lewek M et al Clin
Biomech 2002
Quad wknss (< 80%
uninvolved) led to
significant gait
alterations in early
stance with walking
and jogging
“Quad avoidance gait”Timoney JM et al AJSM
1993
Proprioception and Gait

Zatterstrom et al. AJSM
1994- found balance
disturbance/deficiencies at BOTH
LE’s after ACL rupture versus
controls
•****Underlies the importance
of early closed chain exercise
to facilitate return of
proprioception at BOTH LE’s.
Gait and Proprioceptive Training
Principles



Begins at initial eval-don’t allow
continued reinforcement of abnormal
inefficient gait- will be more difficult
to break later in rehab
Progress out of brace/immobilizer
ASAP to facilitate normal gait and
ROM
Early WB will enhance proprioception
restoration.
Normalizing Gait



Early weight shifts- multi-planar
Cup Drill/Hurdle Walking
Balance/Perturbation beginning bilaterally
on tilt board/variable surface and
progressing to single LE. Begin @ 30°
knee flx (most quad/hams cocontraction
on EMG = SAFER FOR GRAFT
INITIALLY!!!). Wilk KE et al Orthop Clin
N Amer 2003.
Normalized Gait Assessment ?
BREAK
Essential Components of PostOperative S & C Programs







OKC vs. CKC?
Isolated vs. Multi-Joint Exercises?
Eccentric and Concentric Loading
Anterior Chain Strength
Posterior Chain Strength
Core Strengthening
Plyometrics
Eccentric Exercise Considerations
for Max. Strength Return



Gerber JP et al JBJS Am. 2007
Gerber JP et al Phys Ther 2009
Eccentric training beginning 3 wks
s/p ACLR induced greater gains in
glute and quad volume and strength
without deleterious effects (i.e. graft
laxity, etc.) up to 1 yr post-op
Strength Exercise Selection



Escamilla R et al.
JOSPT 2012
NWB exercises gen.
load ACL more than
WB exercises
For NWB and WB exer.
ACL is loaded more
between 10-50° versus
50-100° knee flx ROM
OKC vs. CKC Exercise
Selection Considerations
Open Kinetic Chain (OKC) vs. Closed
Kinetic Chain (CKC)- Impact on ACL
Beynnon B et al Clin Ortho Related Res.
2002 (review)

• Largest ACL strain values produced by isometric and
isotonic contraction of the quads with the knee near full
extension
• ↑ resist. during active knee ext motion and OKC exer.
that does not involve body weight loading and
appreciable cocontraction generates ↑ in ACL strain.
• Rehab with CKC program (vs. OKC) results in:


a-p knee laxity values that are closer to normal
earlier return to normal daily activities
Surprising ACL Strain Values
CKC- Squat/ Leg Press/ Lunge
Considerations





Escamilla RF et al. JOSPT 2012
No change in ACL strain with squat
no resistance vs. up to 30 lbs. resist.
Grtr. ACL load with single LE vs.
double LE squat
Forward trunk tilt dec. ACL load by
inc. hams activation
Leg Press at higher knee flx angles
when ROM is available to dec. ACL
strain
Closed Kinetic Chain (CKC)
Functional Exercise Considerations



Asymmetrical loading differences @
involved vs. uninvolved LE with parallel
squat were greatest in s/p ACLR group @
1.4-4 mos. post-op
Did not equalize until 12-15 mos. Post-op
Neitzel JA et al. Clin. Biomechanics
2002
Squat/wall slide- Mirror and/or bathroom
scale under each foot to assist selfcorrection of asymmetry with weight
bearing.
Closed Kinetic Chain (CKC)
Functional Exercise Progressions
Step Downs (front
and lateral)- Strong
correlation between
fxnl scores and front
step down
performance.
Chmielewski TL et
al Gait Posture
2002
Closed Kinetic Chain (CKC)
Functional Exercise Progressions

Variables
• Surface: AIREX pads, Dynadisks, BOSUstimulate proprioceptive feedback
• Planes: Don’t forget frontal and oblique planes
with lunges, etc.
• Speed
• Resistance- can increase safely without risk to
ACL graft
• Height
• Incorporation of UE involvement/external
challenges
OKC considerations
OKC exer. not
typically fxnl
(unless soccer
player or martial
artist), but may
better isolate indvdl
muscle grp
• ACL injuries
usually in WB/CKC
• OKC P-F jt. rxn
forces > CKC
•
BREAK
Importance of Core Stability
“The Butt and The Gut”
Gluteus Maximus
Transverse
Abdominus
Gluteus Medius
Gluteus Minimus
Quadratus
Lumborum
Deep Rotators
Multifidi
External and Internal
Oblique
Importance of Core/Hip Stability


Markolf KL et al JBJS 1978Muscular contraction can ↓
valgus/varus laxity of knee threefold.
Help with control of ↑ tibial ER in WB
(already discussed), by limiting
femoral IR via increased strength at
glutes and hip ext. rotators Powers
CM JOSPT 2003 and Powers CM
APTA ACP Course 2008.
Gold Standard for Core Stability
Assessment



No current consensus
about best method
Multiple definitions of
core stability exist
May evaluate power,
proprioception, postural
stability, etc.
Weir et al. Clin J Sport Med 2010

Found INSUFFICIENT reliability of 6
tests for core stability including:
• Single LE squat
• Lat. Step down
• Bridging
• Prone plank
• Observation of standing dynamic trunk
control in sagittal, frontal, and
transverse planes
Core Stability Evaluation
• Assessment:





Step Down Test (Watch for Femoral IR/Knee
Valgus, lateral trunk flexion)
Bridges and progressions- look for ability to
maintain ASIS level in single LE hold
Planks/Side planks- decrease support via
hip ext. or punch with plank and hip abd
with side plank. Can they perform?
MMT/Strength of hip abductors, extensors
and external rotators
Knee and trunk deviations with lunging
progressions
Step Down Test Ant View
Step Down Test Lat. View
Traveling Lunge Assessment
Core Progressions
Sagittal Plane
Frontal Plane
Transverse Plane
Combined Planes
Core Stability- Ant. Pelvic Tilt




Delp SL et al. J Biomech 1999
Shultz SJ (2007) Understanding and
Preventing non-contact ACL injuries
Human Kinetics pp. 239-258
Ant. Pelvic Tilt places hip in ↑ Fem.
IR, anteversion and ↑ flx=
lengthened and weaker hamstrings
and altered moment arm at glutes
Ant .pelvic tilt increases genu valgus
and subtalar pronation
Anterior Progressions
Abdominal Bracing
Plank
Push Up
Plank with UE/LE Challenges
Roll Outs
Roll Outs
Lateral Core Progressions
Side Support
Side Plank
Side Bridge
Side Plank with Star
Suitcase Carries
Side Plank and Star
Rotational Stability
Maintain a stable
foundation while
creating rotational
power
Essential Skill for
Sport
-Baseball
-Soccer
-Hockey
-Golf
Progressions
Pallof Press
Chop/Lift
Side Plank with Row
Rotational Plank
Medicine Ball Shot
Putt
Medicine Ball
Rotational Throw
Pallof Press
Cable Chop
Side Plank with Row
Rotational Plank
Gluteus Medius
Essential in Pelvic
Alignment
Major Player in
Dynamic LE
Alignment
Key Stabilizing
Muscle
For the knee and
ankle
Research
Powers et al. JOSPT 2011, 2012
Davis et al. JOSPT 2010, 2011
Ireland et al. Med Sci Sports Exerc.
2006,
J Am Acad Orthop. Surg 2005
More Research….
Bolga LA, Uhl TL. Electromyographic Analysis
of Hip Rehabilitation Exercises in a Group of
Healthy Subjects. JOSPT 2005
Ekstrom RA, Donatelli RA, Carp KC. EMG
Analysis of Core Trunk, Hip, and Thigh
Musculature During Common Therapeutic
Exercises. JOSPT 2007
Distefano LJ, Blackburn JT, Marshall SW,
Padua DA. Gluteal Muscle Activation During
Common Therapeutic Exercises. JOSPT 2009
Take Home Message
Gluteus Maximus: Single Limb Squat
Gluteus Medius: Sidelying Hip Abduction
Hamstrings: Unilateral Bridge
External Oblique/Rectus Abdominus:
Plank
Multifidi: Unilateral Bridge
CKC Gluteus Maximus
Progressions
Bridge
Bridge with March
Hip Lift
Thrust
Hinge
Pull Through
Rack Pull to Deadlift Progressions
SL Deadlift
Bridge Progressions
Hip Thrust
Hip Hinge
Pull Through
Single Leg Deadlift
SLDL with rotation
OKC Gluteus Maximus
Progressions
Bird Dog (Knee
Flexed)
Hydrant
Hyper
Hyper off Table
OKC Gluteus Medius
Progressions
Standing Abduction with IR
Clam Shell
Concentric/Eccentric Clam Shell
Band or Cable Resisted Abduction
Sidelying Abduction (Against Wall)
Side Plank Star
Clam Shells
Manually Resisted Clam Shells
CKC Gluteus Medius
Progressions
Band Walk at Knees
Band Walk at Ankles
Band Walk at Toes
Step Down
Single Leg Squat
Pistol Squat
Band Walk
Pistol Squat
Hamstring function and training




Core muscle via attachment at ischial
tuberosity
Backup stabilizer to ACL to prevent
ant. tibial translation
Assist with tibiofemoral rot. Control
Must receive appropriate attention
(i.e. concentric and eccentric
training). Often functions
eccentrically during sport
Posterior Chain Progressions
Hinge with Staff
Pull Through
Deadlift
Single Leg Dead Lift
Physioball DKTC
Slide Board Eccentric Hamstring
Russian Hamstring
Slide Board Eccentric
Hamstring
Eccentric Hamstring- Russian/
Nordic Leg Curl
Physioball DKTC/Theraball Leg
Curl
Multi-Joint Progressions
Split Squat
Rear Foot Elevated Split Squat
Reverse Lunge
Lunge
Lateral Lunge
Transverse Lunge
Multi Joint Progressions
Gastroc-Soleus Function



Gastrocnemius contraction results in ↑ ACL
strain- results in ant. tib. translation by
pulling femur posteriorly. Kvist J Sports
Med 2004
Soleus acts as ACL agonist by stabilizing
tibia posteriorly in closed chain. Cascio
BM Clin Sports Med 2004
****Importance of including gastrocsoleus exercises in rehab program,
specifically with knee flexed to increase
soleus focus
Retro Training


Functionally critical
for some sports
(backpedal and
change of directioni.e. soccer,
basketball, tennis,
football, etc.)
Vary and diversify
recruitment of
quadricepsimprove
neuromuscular
activation
Retro Training

Cipriani DJ et al. JOSPT 1995- Retro
walking on inclined treadmill produces:
• ↑ knee flx ROM
• ↑ challenge to rectus femoris during
propulsion phase
• normal eccentric contraction of rectus femoris
is replaced by concentric contraction= less
potential for ant. knee pain

Flynn TW et al. JOSPT 1995- Backward
running at self-selected speed may:
• reduce p-f compressive forces
• ↑ quad strength and power
• Quads active longer during stance phase than
during forward running.
Retro Training Examples
• Retrowalk on inclined treadmill
• Retrowalk with superband with
progression to Retrorunning when
appropriate
• Retro StairMaster and Elliptical
Band Resisted Retrowalking
Band Resisted Retrorunning
Incorporate Rotational Activties







Single leg dead lift with rotation
Multi-Planar Lunges with rotation
90°/180° jumps (double LE→single)
Carioca agility
Figure 8 running
45° angle cuts and hops
****Rotation will significantly stress graft.
Delay these activities until 14-16 wks.
post-op to allow graft maturation and
stability.
Dynamic Rotational ExercisesWarmup
Perturbation Training- Operational
Definition



Chmielewski TL et al Phys. Ther.
2005
Pts. are exposed to carefully
controlled forces that destabilize
knee joint- allows motor learning and
skill acquisition
“Provides stimulus for reorganizing
muscle responses that may
ultimately lead to improved fxn”
Why Perturbation Training…..Unexpected Challenges ?
Perturbation Training Evidence

Fitzgerald GK et al Phys. Ther. 2000,
Chmielewski TL et al Phys. Ther. 2005
• Improved long-term maintenance of fxnl and
proprioceptive rehab gains in ACL-deficient
pts. (versus control group without perturbation
training) and higher scores on fxnl tests
• ↓ co-contraction “stiffening” pattern, allows pt.
to ↑ selective muscle activity and movements,
normalized kinematics .
• ↑ carryover of protective response to fxnl
situations improves patient safety with return
to sport and unpredictable demands and/or
unstable positions
Perturbations Implementation
Alter:
• Predictability
• Speed
• Amplitude
• Direction
• Intensity
Perturbation Training- Proximally
Proximal Challenges
Perturbation Training- Distally
Perturbation TrainingCoordinated with UE
Perturbation Training
Perturbation Training- High
Speed
Perturbation Training- Sport-specific
Return to Running Progression